MEDICARE: EXECUTIVE PRODUCERS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	34392	TX

General Provider Information

NPI Number	:	1205132065
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXECUTIVE PRODUCERS

Provider Business Mailing Address
First Line	:	8413 PALO DURO CT
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-6842
Country	:	US
Telephone Number	:	972-800-5878
Fax Number	:	972-386-8597

Provider Business Practice Location Address
First Line	:	4150 INTERNATIONAL PLZ
Second Line	:	STE 600
City	:	FORT WORTH
State	:	TX
Zip	:	76109-4892
Country	:	US
Telephone Number	:	972-800-5878
Fax Number	:	972-386-8597

Authorized Official
Title or Position	:	CEO
Name	:	DR. ESTHER LOCKART
Credential	:	PH.D.
Telephone Number	:	972-800-5878

Provider Enumeration Date	:	01/26/2011
Last Update Date	:	01/26/2011

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